Canadian Hypertension Society Research Articles

The 2010 Canadian Hypertension Education Program recommendations for the management of hypertension: Part 2 – therapy

To update the evidence-based recommendations for the prevention and treatment of hypertension in adults for 2010. For lifestyle and pharmacological interventions, randomized trials and systematic reviews of trials were preferentially reviewed. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. However, for lifestyle interventions, blood pressure lowering was accepted as a primary outcome given the general lack of long-term morbidity and mortality data in this field. Progressive renal impairment was also accepted as a clinically relevant primary outcome among patients with chronic kidney disease. A Cochrane Collaboration librarian conducted an independent MEDLINE search from 2008 to August 2009 to update the 2009 recommendations. To identify additional studies, reference lists were reviewed and experts were contacted. All relevant articles were reviewed and appraised independently by both content and methodological experts using prespecified levels of evidence. For lifestyle modifications to prevent and treat hypertension, restrict dietary sodium to 1500 mg (65 mmol) per day in adults 50 years of age or younger, to 1300 mg (57 mmol) per day in adults 51 to 70 years of age, and to 1200 mg (52 mmol) per day in adults older than 70 years of age; perform 30 min to 60 min of moderate aerobic exercise four to seven days per week; maintain a healthy body weight (body mass index 18.5 kg/m(2) to 24.9 kg/m(2)) and waist circumference (less than 102 cm for men and less than 88 cm for women); limit alcohol consumption to no more than 14 standard drinks per week for men or nine standard drinks per week for women; follow a diet that emphasizes fruits, vegetables and low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources, and that is low in saturated fat and cholesterol; and consider stress management in selected individuals with hypertension. For the pharmacological management of hypertension, treatment thresholds and targets should be predicated on the patient's global atherosclerotic risk, target organ damage and comorbid conditions. Blood pressure should be decreased to less than 140/90 mmHg in all patients, and to less than 130/80 mmHg in patients with diabetes mellitus or chronic kidney disease. Most patients will require more than one agent to achieve these target blood pressures. Antihypertensive therapy should be considered in all adult patients regardless of age (caution should be exercised in elderly patients who are frail). For adults without compelling indications for other agents, considerations for initial therapy should include thiazide diuretics, angiotensin- converting enzyme (ACE) inhibitors (in patients who are not black), long-acting calcium channel blockers (CCBs), angiotensin receptor blockers (ARBs) or beta-blockers (in those younger than 60 years of age). A combination of two first-line agents may also be considered as initial treatment of hypertension if systolic blood pressure is 20 mmHg above target or if diastolic blood pressure is 10 mmHg above target. The combination of ACE inhibitors and ARBs should not be used, unless compelling indications are present to suggest consideration of dual therapy. Agents appropriate for first-line therapy for isolated systolic hypertension include thiazide diuretics, long-acting dihydropyridine CCBs or ARBs. In patients with coronary artery disease, ACE inhibitors, ARBs or betablockers are recommended as first-line therapy; in patients with cerebrovascular disease, an ACE inhibitor/diuretic combination is preferred; in patients with proteinuric nondiabetic chronic kidney disease, ACE inhibitors or ARBs (if intolerant to ACE inhibitors) are recommended; and in patients with diabetes mellitus, ACE inhibitors or ARBs (or, in patients without albuminuria, thiazides or dihydropyridine CCBs) are appropriate first-line therapies. In selected high-risk patients in whom combination therapy is being considered, an ACE inhibitor plus a long-acting dihydropyridine CCB is preferable to an ACE inhibitor plus a thiazide diuretic. All hypertensive patients with dyslipidemia should be treated using the thresholds, targets and agents outlined in the Canadian lipid treatment guidelines. Selected patients with hypertension who do not achieve thresholds for statin therapy, but who are otherwise at high risk for cardiovascular events, should nonetheless receive statin therapy. Once blood pressure is controlled, low-dose acetylsalicylic acid therapy should be considered. All recommendations were graded according to the strength of the evidence and voted on by the 63 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 80% consensus. These guidelines will continue to be updated annually. The Canadian Hypertension Education Program process is sponsored by the Canadian Hypertension Society, Blood Pressure Canada, the Public Health Agency of Canada, the College of Family Physicians of Canada, the Canadian Pharmacists Association, the Canadian Council of Cardiovascular Nurses, and the Heart and Stroke Foundation of Canada.

Hypertension in diabetes: A call to action

The Canadian Hypertension Education Program, Blood Pressure Canada, Canadian Hypertension Society, Heart and Stroke Foundation of Canada, Canadian Diabetes Association, College of Family Physicians of Canada, Canadian Pharmacists Association and the Canadian Council of Cardiovascular Nurses call on Canadian health care professionals to redouble efforts to help patients achieve treatment targets (blood pressure less than 130 mmHg systolic and less than 80 mmHg diastolic) in people with diabetes. Treatment of high blood pressure in people with diabetes results in large reductions in death and disability within a short period of time and needs to be a therapeutic priority. Achieving blood pressure targets requires sustained lifestyle modification, and three or more drugs including a diuretic are often required. Antihypertensive treatment in people with diabetes is one of the few medical treatments estimated to reduce overall health costs. The cost of treatment is less than the cost of complications prevented. Blood pressure needs to be assessed at all visits and home blood pressure assessment is encouraged. Management strategies need to include assessment and management of cardiovascular risks including smoking, unhealthy eating, physical inactivity, abdominal obesity, dyslipidemia as well as dysglycemia. The risks and benefits of acetylsalicylic acid in primary prevention of cardiovascular disease are uncertain in people with hypertension and diabetes. Intensive individualized lifestyle modification is recommended to prevent and treat hypertension, dyslipidemia, dysglycemia and other vascular risks in people with diabetes.

The Newly Identified Hypertensive Patient: Cost‐Effective Laboratory Investigation

The Newly Identified Hypertensive Patient: Cost‐Effective Laboratory Investigation

An International Benchmarking Collaboration: Measuring Outcomes for the Hypertensive Disorders of Pregnancy

ObjectiveTo implement a set of clinical indicators to benchmark outcomes for women suffering from the hypertensive disorders of pregnancy. MethodsSeven clinical indicators were designed and applied retrospectively to data collected from two tertiary referral centres, Royal Prince Alfred Hospital, Sydney, Australia and British Columbia Women’s Hospital and Health Centre, Vancouver BC, for all women coded as hypertensive during pregnancy under the International Classification of Disease (ICD-10) coding system in the years 2002–2004. Diagnostic categories were assigned using the Australasian Society for the Study of Hypertension in Pregnancy criteria, expressed in equivalent Canadian terms drawn from the Report of the Canadian Hypertension Society Consensus. Comparisons were made using the established clinical indicators. Data analysis using chi-square comparison was performed with significance set at P < 0.05. Seven outcome measures of maternal and neonatal mortality and morbidity were compared. ResultsSignificant areas of difference between the two tertiary referral centres were seen in birth weights below the 10th centile (RPA 11% vs. BCW 20%; P < 0.05) and below the 3rd centile (RPA 1.5% vs. BCW 7.5%; P < 0.001). There were significantly more episodes of maternal pulmonary edema at BCW than at RPA (0.1% and 1.2%, respectively; P < 0.001). ConclusionBetween similar centres, clinically significant differences in outcomes for HDP were identified. Further evaluation of differences may lead to analysis of possible contributors such as expectant versus urgent delivery management policies, rigidity of blood pressure control, and choice of antihypertensive drug.

Canada Chair in hypertension prevention and control: A pilot project

A five-year pilot project was initiated in Canada to fund an individual to lead the effort in improving hypertension prevention and control. As the initial recipient of the funding, the author's objectives were to provide leadership to improve the management of hypertension through enhancements to the Canadian Hypertension Education Program, to increase public knowledge of hypertension, to reduce the prevalence of hypertension by reducing dietary sodium additives and to develop a comprehensive hypertension surveillance program. The initiative has received strong support from the hypertension community, the Public Health Agency of Canada, the Heart and Stroke Foundation of Canada, and many Canadian health care professional and scientific organizations. Progress has been made on all objectives. The pilot project was funded by The Canadian Hypertension Society, the Canadian Institutes of Health Research and sanofi-aventis, in partnership with Blood Pressure Canada, and will finish in July 2011.

Public education on hypertension: A new initiative to improve the prevention, treatment and control of hypertension in Canada

High blood pressure is one of the leading risk factors for death. Nevertheless, there is a lack of awareness of hypertension as a risk factor, as well as significant misconceptions about hypertension in the Canadian population. Furthermore, according to the Canadian Heart Health Surveys (1985 to 1992), 42% of hypertensive adult Canadians are unaware of their hypertensive status. A collaboration between Blood Pressure Canada, the Heart and Stroke Foundation of Canada, the Canadian Hypertension Society and the Canadian Hypertension Education Program has been formed to improve public and patient awareness and knowledge of hypertension. The effort will involve the translation of Canadian Hypertension Education Program recommendations for the prevention and management of hypertension to a public level with a broad and evolving dissemination strategy; the training of health professionals to speak to the public and patients on hypertension, coupled with opportunities to speak in forums organized in their local communities; and, media releases and information on hypertension in association with World Hypertension Day and the release of the annually updated public recommendations. Based on higher rates of awareness of hypertension in countries with sustained public education programs on hypertension, it is anticipated that this evolving program will result in improvement in the rates of awareness, treatment and control of hypertension and, ultimately, in lower cardiovascular disease rates in Canada. Public health programs that could reduce the prevalence of hypertension will be integrated into key public recommendations. The program outcomes will be monitored using Statistics Canada national surveys and by specific surveys examining hypertension knowledge in the Canadian population.

Lifestyle Modifications to Prevent and Manage Hypertension for Exercise Physiologists and Fitness Professionals

Information tailored to the interest of exercise physiologists and fitness professionals is provided regarding the Canadian Hypertension Society's 2005 evidence-based recommendations on lifestyle modifications for the prevention and management of hypertension. The evidence from randomized controlled (RC) trials and systematic reviews of RC trials published in peer reviewed journals was reviewed by subject matter experts and then appraised independently by content and methodology experts. Blood pressure lowering was accepted as a primary outcome. All recommendations were debated and then voted on by the 43 members of the Canadian Hypertension Education Program's Evidence-Based Recommendations Task Force and achieved at least 95% consensus. Lifestyle modifications to prevent and/or manage hypertension include: (1) perform 30-60 minutes of aerobic exercise on 4- 7 days of the week; (2) maintain a healthy body weight (BMI 18.5-24.9 kg/m2) and waist circumference (<102 cm for men and <88 cm for women); (3) limit alcohol consumption to no more than 14 standard drinks per week in men or 9 standard drinks per week in women; (4) follow a diet that emphasizes fruits, vegetables, and low-fat dairy products and which is reduced in fat and cholesterol (DASH diet); (5) restrict salt intake; and (6) consider stress management in selected individuals.

Treatment gaps for hypertension management in rural Canadian patients with type 2 diabetes mellitus

Background: There were a reported 2.2 million Canadians living with diabetes mellitus (DM) in 2002, of whom 1.98 million (90.0%) had type 2 DM. In addition, there are ∼60,000 new cases of type 2 DM diagnosed in Canada each year. However, the research shows that evidence and guidelines for management of hypertension in DM are not always translated into clinical practice. In rural areas, factors affecting implementation of recommendations and/or guidelines are less well understood, although some studies suggest that urban practices provide higher quality of care overall than rural areas. Objective: The goal of this study was to describe the patterns of medication use for hypertension for patients with type 2 DM in rural northern Alberta, Canada. We also tried to identify treatment gaps and opportunities for prescribing antihypertensives relative to the Canadian Diabetes Association's 1998 Clinical Practice Guidelines for the Management of Diabetes in Canada and the Canadian Hypertension Society Recommendations Working Group's 2003 Canadian Recommendations for the Management of Hypertension: Therapy. Methods: This study was conducted at the Institute of Health Economics and the University of Alberta (Edmonton, Alberta, Canada). We collected information from a cohort of patients aged ≥20 years with type 2 DM living in 2 adjacent rural regions of northern Alberta, Canada, at the time of enrollment in a diabetes care quality-improvement program as part of the Diabetes Outreach Van Enhancement (DOVE) study. Treatment gaps were determined by comparing antihypertensive pharmacotherapy with a blood pressure (BP) target of ≤130/≤85 mm Hg. We used multivariate regression analyses to determine the associations between sociodemographic and clinical characteristics and treatment gaps. Results: A total of 392 patients (229 women, 164 men; mean [SD] age, 62.3 [12.5] years) with type 2 DM were included in this analysis. Patients had a mean (SD) duration of diabetes of 8.3 (8.5) years. A total of 75.8% ( 297 392 ) of the study population had hypertension, and most ( 236 392 [60.2%]) were receiving some pharmacotherapy. Treatment gaps were present; 42.7% (n = 67) of patients not receiving pharmacotherapy for hypertension were above the established BP targets. For patients receiving monotherapy, 70% were not at BP targets. For patients receiving dual, triple, and ≥4 medications, 65%, 66%, and 46%, respectively, were not at BP targets. After controlling for systolic blood pressure, male sex (adjusted odds ratio [aOR], 2.17; 95% CI, 1.17–4.03), older age (aOR, 1.80 per decade; 95% CI, 1.51–2.09), lower self-reported physical health (aOR, 0.68; 95% CI, 0.41–0.96), higher body mass index (aOR, 1.05; 95% CI, 1.01–1.10), and past/current smoking (aOR, 1.95; 95% CI, 1.01–3.76) were all significantly associated with a lack of treatment for hypertension. Conclusions: Treatment maps in the management of hypertension exist in these rural Canadian patients with type 2 DM. Cardiovascular risk may be underestimated in these patients, particularly among younger patients and women, and those with multiple non-DM risk factors. These are patient subgroups that should be targeted as opportunities to improve hypertension management at the population level.

A Survey of Canadian Practitioners Regarding the Management of the Hypertensive Disorders of Pregnancy

Background: How Canadian practitioners are managing the hypertensive disorders of pregnancy (HDP) is not known, particularly in relation to the 1997 guidelines published by the Canadian Hypertension Society (CHS). Methods: A survey, with French and English versions (and covering diagnosis, evaluation, and management of pregnancy hypertension), was mailed to all members of the Society of Obstetricians and Gynaecologists of Canada (SOGC) (N = 1757, including obstetricians, family doctors practicing obstetrics, and midwives). Additionally, internists [i.e., all nephrologists (N = 191) and a random sample of 25% of general internists (N = 450)] registered with the Royal College of Physicians and Surgeons of Canada were sampled. The survey was distributed in two mailings and one reminder card. Data were entered into Microsoft Access, and Graph Pad Prism used to summarize responses [N (%)]. Differences in practice between specialties were examined, with a Bonferroni correction used to calculate a significant p value based on the number of comparisons and alpha of 0.05. Results: Respondents numbered 1187 (49.5%), with 466 not informative for the purpose of the study (due to retirement, or practices that do not include pregnant women with hypertension). The final analysis included 721 completed surveys. For all types of HDP, most internists, family doctors, and midwives initiate nonpharmacological therapy (most common advice to quit work) at dBP 80–89 mmHg (i.e., primary prevention). Only for preeclampsia do obstetricians most frequently use this threshold; otherwise, dBP 90–99 mmHg is usually chosen. For nonsevere hypertension, antihypertensive drug therapy (most commonly methyldopa or labetalol) is started by most practitioners at dBP 90–99 mmHg, although obstetricians are more likely to choose a higher threshold (p < 0.0001). There is little agreement about dBP treatment goal; most internists and family doctors normalize dBP, whereas obstetricians appear to be divided on dBP goals of 80–89 (46–51%) vs. 90–99 mmHg (41–44%) for all HDP (p = 0.66). Severe hypertension is commonly treated with parenteral hydralazine, labetalol, or magnesium sulphate. Short‐acting or sustained release nifedipine is used rarely/never by most practitioners. Approximately one‐third of obstetricians and family doctors use diazepam to treat eclampsia. The vast majority use MgSO4 prophylactically in women with preeclampsia. Interpretation: This survey has clarified current stated management of women with HDP, and identified the need for both research into the dBP treatment goal that optimizes pregnancy outcomes among women with HDP, and translation of definitive studies into clinical practice.

A Survey of Canadian Practitioners Regarding Diagnosis and Evaluation of the Hypertensive Disorders of Pregnancy

Background: How Canadian practitioners are diagnosing and managing the hypertensive disorders of pregnancy (HDP), particularly in relation to the 1997 recommendations published by the Canadian Hypertension Society (CHS), is not known. Methods: A survey, with French and English versions (and covering diagnosis, evaluation, and management of pregnancy hypertension), was mailed to all members of the Society of Obstetricians and Gynaecologists of Canada (SOGC) (N = 1757, including obstetricians, family doctors practicing obstetrics, and midwives). Additionally, internists [i.e., all nephrologists (N = 191) and a random sample of 25% of general internists (N = 450)] registered with the Royal College of Physicians and Surgeons of Canada were sampled. The survey was distributed in two mailings and one reminder card. Data were entered into Microsoft Access, and Graph Pad Prism used to summarize responses [N (%)]. Differences in practice between specialties were examined, with a Bonferonni correction used to calculate a significant p value based on the number of comparisons and alpha of 0.05. Results: Respondents numbered 1187 (49.5%), with 466 not informative for the purpose of the study (due to retirement, or practices that do not include pregnant women with hypertension). The final analysis included 721 completed surveys. Most (609, 84.5% of) respondents take blood pressure (BP) with women in the sitting position, and use a mercury sphygmomanometer (79%) and the 5th Korotkoff (61%) sound to designate diastolic BP (dBP). To monitor pregnancies complicated by preeclampsia, most clinicians use the proposed laboratory tests of maternal well‐being (usually at least once/week), fetal well‐being [nonstress test (NST, at least once/week), and ultrasonographic studies (once weekly to every two weeks)]. There is general agreement that women with preeclampsia should be delivered for uncontrolled hypertension, end‐organ dysfunction, or fetal compromise (nonreassuring NST, severe oligohydramnios, biophysical profile < 4, estimated fetal weight < 5th centile, and reversed end‐diastolic flow by umbilical artery Doppler velocimetry). Less consensus was seen for delivery for preeclampsia at > 34 weeks, mild asymptomatic HELLP syndrome, hyperreflexia, and absent end‐diastolic flow by umbilical artery Doppler velocimetry. Interpretation: This survey has clarified the current state of practice with respect to the diagnosis and evaluation of women with all types of HDP. In particular, we have identified areas of potential variability in BP measurement, and provided data on the feasibility of enrolling women with sub types of preeclampsia into intervention studies aimed at prolonging pregnancy.

Introduction

Introduction

Review: Pharmacologic treatment of hypertension during pregnancy reduces perinatal deaths and severe maternal hypertension

Source Citation Rey E, LeLorier J, Burgess E, Lange IR, Leduc L. Report of the Canadian Hypertension Society Consensus Conference: 3. Pharmacologic treatment of hypertensive disorders in pregnancy. CMAJ. 1997 Nov 1; 157:1245-54.

A survey of management practices for isolated systolic hypertension.

To determine the management practices of clinicians for patients with isolated systolic hypertension, with particular attention to treatment thresholds, medication choices, and target blood pressures. Self-administered questionnaire. Edmonton, Alberta, a large Canadian city. A random sample of 348 family physicians and 125 internists. Demographics of the respondents, first and second choice of antihypertensives, treatment thresholds, and target blood pressures for patients with isolated systolic hypertension. Excluding 54 nondeliverable questionnaires, a response rate of 67% (281 surveys) was obtained. The responding clinicians reported treatment thresholds and target blood pressures consistent with the evidence from randomized clinical trials and the recommendations of the Canadian Hypertension Society and the Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Thiazide diuretics were recommended as first line therapy by 74% of internists and 58% of family physicians. Angiotensin converting enzyme inhibitors were the most frequently chosen second line drug (27% of internists and 45% of family physicians). The reported management practices of this group of clinicians are consistent with the evidence from randomized clinical trials and the recommendations of national consensus guidelines.

Antihypertensive therapy debate: contribution from the Shanghai Trial Of Nifedipine in the Elderly (STONE).

In 1993, a number of influential bodies reported the results of consensus conferences on the management of hypertension, including the World Health Organization/International Society of Hypertension, the fifth United States Joint National Committee (JNC-V), the British Hypertension Society, the Canadian Hypertension Society (CHS) and the New Zealand National Advisory Committee. Most of these guidelines were in general agreement. The most significant difference was in the choice of first-line agents, whether to use only beta-blockers or thiazides (JNC-V/CHS) or to use any of the five major classes of antihypertensive agents. At present, this is the only placebo-controlled trial on newer classes of medications for which results are available. The trial has both strengths and weaknesses. Among the strengths of this trial is the comparability of the subjects in both arms and the robustness of the results. STONE does at least suggest that outcomes with newer agents like long-acting nifedipine are comparable to outcomes in major clinical trials in the elderly using diuretics and beta-blockers.

Hypertension: Blood pressure regulating systems: cellular, integrative, and therapeutic aspects

This is only the second time in the long history of the International Physiological Congresses that a symposium on hypertension has formed part of the official satellite programme. After the 1983 IUPS Congress in Sydney, John Chalmers organized a magnificent satellite meeting at the Flinders Medical Centre in South Australia and we felt that we wished to continue the "tradition." Hypertension research has provided a wonderful example in recent years of how exciting it can be to apply very basic discoveries to the solution of practical problems. This meeting breaks new ground in being the first scientific event sponsored jointly by the Canadian Hypertension Society and the Australian High Blood Pressure Council. The meeting was made possible by generous financial support from Pfizer Canada and Pfizer Australia with, as co-contributors, Bayer Germany and Sandoz Australia. We would also like to acknowledge the help of Mrs. A. Garat of Pfizer Canada Medical Services in the organization of the meeting and Dr. Andrew Rankin who was responsible for all local arrangements.The Hypertension Satellite was held at Whistler, B.C., July 19–21, 1986, following the 30th International Congress of the International Union of Physiological Sciences in Vancouver. It provided a good forum for interdisciplinary information exchange. It also proved to be a pleasant social occasion in the beautiful setting of the coastal range of the Canadian Rockies. There were 48 invited speakers from Canada, Australia, Europe, the U.S.A., Japan, and New Zealand. We were fortunate in having as our patrons two great names in hypertension research, Dr. Arthur Guyton and Dr. Sydney Friedman.Emphasis was on a large range of mechanisms that regulate blood pressure. There were sessions on cell biology, the kidney, autonomic nervous regulation, peptides (including, of course, atrial natriuretic peptide and arginine vasopressin), and pathogenesis. The proceedings provide an up-to-date account of the position of the current "state of the art" in a number of important areas.

Nutritional management of hypertension: controversies and frontiers. Proceedings of one more meeting?

In recent years antihypertensive therapy has evolved from treatment for a relatively small number of patients with severe hypertension to treatment for millions of people with mild to severe hypertension. We now treat not only patients at high risk for future cardiovascular morbidity and mortality, of whom nearly all are benefitting from antihypertensive therapy, but also much larger groups of patients each individually at low risk. In this latter group only a small percentage actually benefits from antihypertensive therapy. For example, in the Australian trial in subjects with mild hypertension and no other evidence of cardiovascular disease, only two excess deaths were prevented at the expense of 1000 patient-years of drug treatment (Australian Therapeutic Trial 1980). For most individual members of this group normalizing their mild blood pressure elevation appears to offer no benefit, yet all of them are exposed to antihypertensive therapy and its side effects. When instituting antihypertensive pharmacotherapy in patients with mild hypertension one has to be concerned about these side effects, not just the objective ones (e.g., effects on plasma lipoproteins or glucose which may offset any gains to be obtained by lowering blood pressure), but also subjective ones (e.g., fatigue, impotence) which may markedly affect the quality of life.Nonpharmacologic, in particular nutritional, management of mild hypertension has intuitively major appeal for "lowering blood pressure without side effects." Many studies have evaluated the effects of dietary changes on blood pressure. Several recent symposia have addressed the issue of nutrition and hypertension. Despite this, the report from the first Consensus Development Conference of the Canadian Hypertension Society ("on the management of mild hypertension in Canada") states "Because of conflicting evidence and problems with patient compliance, the conference had difficulty reaching consensus on the effectiveness of salt restriction and, for the obese, of weight reduction in lowering blood pressure" (Logan 1984).This issue of the Canadian Journal of Physiology and Pharmacology contains the proceedings of a workshop "Nutritional Management of Hypertension: Controversies and Frontiers," held in Harrison Hot Springs, British Columbia, September 6–7, 1985. This workshop was organized under the auspices of the Canadian Hypertension Society and made possible by generous financial support from ICI Pharma, Canada (general sponsorship) as well as from the National Institute of Nutrition for the obesity session, and from the Dairy Bureau of Canada for the sodium–calcium session.To define more clearly the controversies and uncertainties, this workshop was organized in a different way than previous meetings dealing with this issue. A clinical scientist working in a particular area was invited to outline the evidence in favour of a given dietary manipulation for the treatment of hypertension, and another one to outline the evidence against. This evaluation would particularly concern evidence regarding "efficacy" and "effectiveness". A discussant then presented an evaluation of the two position papers, followed by a general discussion and a summary by the session chairman. This type of scrutiny of our current knowledge was done for sodium restriction, calcium supplementation, and weight loss. As part of this evaluation two speakers addressed the closely related issues of practical aspects of diet management (e.g. compliance) and the consequences–risks of weight loss in relation to the pathophysiology of obesity.In the last part of the workshop possible future developments in nutrition and hypertension were reviewed, such as "nutrition in the young, early intervention?," vegetarian approach to hypertension, role of dietary fats, and proteins and precursors.The organizing committee very much appreciated that Dr. David Sackett was willing to serve as the scientific chairman of this workshop, to summarize the present "state of the art" on diet modulation in the management of hypertension as well as to propose recommendations for treatment of hypertension in clinical practice and for future research directions.It was a pleasure for me to serve as chairman of the organizing committee. As President of the Canadian Hypertension Society I would like to thank all session chairmen, speakers, discussants, and participants for their enthusiasm and eagerness to explore the topic of nutrition and hypertension. I hope that the scientific information and insight that the proceedings of this workshop offer will convey their commitment.